The first-ever study to measure medical errors in the perioperative period (immediately before, during and after a surgical procedure) has found that a mistake is made in every other operation. The papers researchers analyzed more than 275 procedures undertaken at Massachusetts General Hospital (MGH), uncovering that a third of the errors resulted in patients being harmed.
The most common mistakes involved incorrect dosages being administered, symptoms indicated by a patients vital signs going untreated and mistakes in medication labeling. Of the adverse drug events that could have led to patients being harmed, 30 percent were considered significant, 69 percent serious and less than 2 percent were deemed to be life-threatening. Longer procedures, particularly those lasting more than six hours, had a higher rate of subsequent problems.
We definitely have room for improvement in preventing perioperative medication errors, and now that we understand the types of errors that are being made and their frequencies, we can begin to develop targeted strategies to prevent them, said Karen C Nanji, the papers lead author. Given that MGH is a national leader in patient safety and had already implemented approaches to improve safety in the operating room, perioperative medication error rates are probably at least as high at many other hospitals.
Prior to our study, the literature on perioperative medication error rates was sparse and consisted largely of self-reported data, which we know under-represents true error rates. Now that we have a better idea of the actual rate and causes of the most common errors, we can focus in developing solutions to address the problems, she added…
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